Social Security Disability Insurance benefits or Supplemental Security Income

Social Security Disability Insurance benefits or Supplemental Security Income

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Your Contact Information

First Name*

Middle Name

Last Name*

Suffix

Email Address

Please Verify Email Address

Phone Number (home, work, mobile, other)

Secondary Phone Number (home, work, mobile, other)

Residence Address *

Street Address (2)

City*

State*

Zip Code*

Do you have a different mailing address?

Mailing Address *

Street Address (2)

City*

State*

Zip Code*

Case Details

Which government agency (or agencies) have you been working with? *

Claimant's Social Security No.

Social Security No. format: XXX-XX-XXXX

Claimant's Date of Birth *

Have you contacted another Congressional office? *

Which office?

When?

Your Request

What do you need help with? *(please describe the problem in as much detail as necessary)

Is there anything else that Senator Merkley or his staff needs to know?

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Once you have reviewed your information on the next page, press the Print and Submit button. This will generate a PDF containing all of the information you have entered as well as a privacy release form. Please print the form, sign and date the last page, and return the form in its entirety to Jeff's Portland office by fax or mail.

Although the information on your form will be submitted to our office electronically, most of the time we cannot open an inquiry on your behalf until we receive your signed form.

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Thank you for contacting me. The information on your form has been submitted electronically to my office. A PDF of your form is being generated automatically and should be ready within 10 seconds. If one is not available to download in that time, click here.

Once we have received your signed authorization, my staff will begin assessing how we can help. Please allow up to 30 days from the day we receive your release for my office to contact you. Thank you.